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dlsorensen

Changing A Rating Code

Question

I filed an original claim for IBS in August of 2008. I was initially given a 0% for 7346 (Hiatal Hernia). I then filed a NOD as I thought I warranted the 30% (daily medication, diarrhea ,substernal arm pain) amount for that rating. The VA came back with a 10%. I appealed this rating in November of last year along with claiming Tinnitus and Sinusitis. My rating just came back Monday with 10% for Tinnitus and 30% for Sinusitus, but no increase in my IBS. My question is this: I feel that I would be better suited to be rated under 7319 for IBS as I easily meet the 30% rating requirements (Take dicyclomine for stomach cramps 4 times a day and have 4 to 5 episodes of diarrhea daily). Can I file a NOD asking that my rating be switched from 7346, which according to the most recent CFR is still Hiatal Hernia to 7319 Irritable Colon with an increase to 30%?

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I filed an original claim for IBS in August of 2008. I was initially given a 0% for 7346 (Hiatal Hernia). I then filed a NOD as I thought I warranted the 30% (daily medication, diarrhea ,substernal arm pain) amount for that rating. The VA came back with a 10%. I appealed this rating in November of last year along with claiming Tinnitus and Sinusitis. My rating just came back Monday with 10% for Tinnitus and 30% for Sinusitus, but no increase in my IBS. My question is this: I feel that I would be better suited to be rated under 7319 for IBS as I easily meet the 30% rating requirements (Take dicyclomine for stomach cramps 4 times a day and have 4 to 5 episodes of diarrhea daily). Can I file a NOD asking that my rating be switched from 7346, which according to the most recent CFR is still Hiatal Hernia to 7319 Irritable Colon with an increase to 30%?

Welcome.

First off your claim was for IBS and Hiatal Hernia was granted.

I would CAREFULLY re-read over that rating decision to see if your

RO even mentioned the condition of IBS.

Let us know exactly what the rating decision states - omit personal info like name & address.

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Evaluation of irritable bowel syndrome (claimed as stomach condition) currently evaluated as 0 percent disabling.

Rating decision dated November 1, 2010, granted service-connection for this condition at a non-compensable level.

The medical evidence indicates chronic abdominal distress with dull aching non radiating aching which has been present for several years. The consult dated November 20, 2008 notes three to four stools per day which are of loose consistency. The examiner specifiacally noted no cramping but did indicate urgency with the stools. There is no blood and Crohn's disease has been ruled out. There is no bloating or distension. Weight has been stable. Treatment reports show 157 pounds on December 20,2008 and February 16, 2009, 155 pounds on September 27, 2009 and 153 pounds on October 14, 2010. You are using Omeprazole daily.

The evaluation of irritable bowel syndrome (claimed as stomach condition) is increased to 10 percent disabling effective July 14, 2009.

An evaluation of 10 percent is assigned from July 14, 2009, the date of receipt of your claim which has remained continuously open due to your appeal and received more than one year following separation from active military service. An evaluation of 10 percent is assigned if there are two or more of the following symptoms: epigastric distress, dysphagia, pyrosis, regurgitation, or substernal or arm or shoulder pain. A higher evaluation of 30 percent is not warranted unless the record shows persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain which is productive of considerable impairment of health.

The evidence of record does not show the symptoms warranting the higher evaluation. Therefore, the 10 percent evaluation is warranted.

This disability is not specifically listed in the rating schedule; therefore , it is rated analogous to a disability in which not only the functions affected, but anatomical localization and symptoms, are closely related.

This decision is considered a partial grant of benefits sought on appeal

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Evaluation of irritable bowel syndrome (claimed as stomach condition) currently evaluated as 0 percent disabling.

Rating decision dated November 1, 2010, granted service-connection for this condition at a non-compensable level.

The medical evidence indicates chronic abdominal distress with dull aching non radiating aching which has been present for several years. The consult dated November 20, 2008 notes three to four stools per day which are of loose consistency. The examiner specifiacally noted no cramping but did indicate urgency with the stools. There is no blood and Crohn's disease has been ruled out. There is no bloating or distension. Weight has been stable. Treatment reports show 157 pounds on December 20,2008 and February 16, 2009, 155 pounds on September 27, 2009 and 153 pounds on October 14, 2010. You are using Omeprazole daily.

Going by the part of the Rating Decision above - this decision maker had evidence of record that warranted a 10 % evaluation.

I feel the original decision maker did rate you under IBS - DC 7346 - but lowballed your percentage.

for IBS -

Rating Criteria :

DC - 7319 Irritable colon syndrome (spastic colitis, mucous colitis, etc.):

"Mild; disturbances of bowel function with occasional episodes of abdominal distress . . . 0"

For a higher evaluation under DC 7319 the medical evidence of record would need to meet

the criteria of :

IMO - the evidence above meets the 10%

"Moderate; frequent episodes of bowel disturbance with abdominal distress . . . 10"

"Severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress . . . 30"

The only factor's referenced above in the medical evidence that relates to 7346 - Hernia Hiatal" are :

"Weight has been stable" and "You are using Omeprazole daily".

Gerd would be a condition that is rated analogous to Hiatal Hernia

but IBS would not

§ 4.20 Analogous ratings.

When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin.

The evaluation of irritable bowel syndrome (claimed as stomach condition) is increased to 10 percent disabling effective July 14, 2009.

An evaluation of 10 percent is assigned from July 14, 2009, the date of receipt of your claim which has remained continuously open due to your appeal and received more than one year following separation from active military service. An evaluation of 10 percent is assigned if there are two or more of the following symptoms: epigastric distress, dysphagia, pyrosis, regurgitation, or substernal or arm or shoulder pain. A higher evaluation of 30 percent is not warranted unless the record shows persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain which is productive of considerable impairment of health.

The evidence of record does not show the symptoms warranting the higher evaluation. Therefore, the 10 percent evaluation is warranted.

Have you left out some of the Reasons and Bases for the rating evaluation here ?

I do not see any medical evidence shown as to WHY they granted an increase to 10 %.

Without knowing exactly what this new medical evidence states - there is no way to even guess

as to what percentage was warranted or even if the increase to 10% was warranted.

This disability is not specifically listed in the rating schedule; therefore , it is rated analogous to a disability in which not only the functions affected, but anatomical localization and symptoms, are closely related.

IMO - this second decision maker that adjudicated your claim for increase, made a grave procedural error, in the assignment and application of a analogous Diagnostic Code.

At the time this decision was made, there most certainly was a Diagnostic Code for IBS - DC 7319.

This decision maker adjudicated an increase from zero percent to 10 percent.

NOTE : DC 7346 does NOT provide for an evaluation of zero percent, this is why I believe the original decision maker

rated you under DC 7319 - as it should be (but lowballed your percentage).

I tried to be a bit more clear - - - than mud : )

carlie

Editing to add that if the Rating Decision has become final - this may be a claim for CUE.

I've sent a shout out to a more knowledgeable member and we might get some more members

posting to help out on this.

This decision is considered a partial grant of benefits sought on appeal

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dis,

This is one of the few times I suggest a call to the 1-800-827-1000 number.

Personally, I would call and ask what is the history showing for my SC'd and non-SC'd disabilities.

Example:

Rating Decision dated Nov 1, 2010

granted SC for what DC ______ with what effective date __/__/____ and at what evaluation ___%.

Were there any issues denied or deferred on this Rating Decision ?

Are there any Non-SC'd conditions shown of record, in this adjudication ?

Your second Rating Decision that granted an increase to 10 %

granted SC or an increase for what DC's ______ with what effective date __/__/____ and at what evaluation ___%.

Were there any issues denied or deferred on this Rating Decision ?

Are there any Non-SC'd conditions shown of record, in this adjudication ?

JMHO

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Let's ignore for the moment that you initially were given a 0% evaluation under the Diagnostic Code for HH. I'd like to back up a bit ...

Do you have a diagnosis of hiatal hernia/GERD at all?

I filed an original claim for IBS in August of 2008. I was initially given a 0% for 7346 (Hiatal Hernia). I then filed a NOD as I thought I warranted the 30% (daily medication, diarrhea ,substernal arm pain) amount for that rating. The VA came back with a 10%. I appealed this rating in November of last year along with claiming Tinnitus and Sinusitis. My rating just came back Monday with 10% for Tinnitus and 30% for Sinusitus, but no increase in my IBS. My question is this: I feel that I would be better suited to be rated under 7319 for IBS as I easily meet the 30% rating requirements (Take dicyclomine for stomach cramps 4 times a day and have 4 to 5 episodes of diarrhea daily). Can I file a NOD asking that my rating be switched from 7346, which according to the most recent CFR is still Hiatal Hernia to 7319 Irritable Colon with an increase to 30%?

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